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Conventional Treatments For Psoriasis

Posted Aug 24 2008 1:49pm
MABEL JONG: Hello, everyone, and welcome to our webcast. I'm Mabel Jong. For the thousands of people suffering from psoriasis, the symptoms, which include flaking, redness and inflammation of the skin, can be uncomfortable and embarrassing. Fortunately, treatments are available to control psoriasis, and some may even induce a remission of the disease.

Joining us to discuss the options, we have Dr. Ken Gordon. He's the director of the Psoriasis Treatment Center at Northwestern University. We also have Dr. Mark Lebwohl, professor and chairman of the department of dermatology at the Mount Sinai School of Medicine. Gentlemen, thanks so much for being with us today.

Now, before we start discussing treatments, can you briefly discuss what psoriasis is?

MARK LEBWOHL, MD: Psoriasis is an inherited disorder of the skin in which immune cells in the skin respond abnormally to external stimuli and release factors that cause the superficial cells of the skin to multiply too quickly. Ordinarily, the superficial layers of the skin make themselves over about every 28 days. In severe psoriasis, those superficial layers can make themselves over every two to four days, and what you see are these thick, red, scaly plaques of skin coming up.

MABEL JONG: What are the goals of treatment?

KENNETH GORDON, MD: I think the goal of treatment for psoriasis really has to be determined by the patient. Each patient has different goals and different things they're looking for. Clearance, really, complete clearance of psoriasis is really not the ultimate goal, because very few patients become completely clear and free of their disease. What you want to do is control it to the point where the patient can be satisfied and go out and do their activities of daily living in a way that's satisfactory to the patient. For each patient, that level is going to be different.

MABEL JONG: Let's talk a little bit now about the treatments. A lot of topical medications are available, Dr. Lebwohl?

MARK LEBWOHL, MD: There are dozens, if not actually hundreds of topical medications, but they fall into a small number of categories. Until recently, certainly, the most commonly prescribed treatment for psoriasis was topical corticosteroids, and there are probably several hundred, or at least 100 of those available worldwide. And they range in strength from very weak to very strong. They come in lotions, solutions, creams, emollient creams, ointments. As a rough rule, the messier they are, the more effective they are, so that ointments are more effective than creams.

There are some old-fashioned treatments that are derived from tar. Tars themselves that are used are anthralin, which is a rather messy treatment that is available for psoriasis.

MABEL JONG: For the topical medications, do you need prescriptions for all of these?

KENNETH GORDON, MD: Except for the weakest topical corticosteroids, that's the hydrocortisone you're able to get over the counter, you are required to have prescriptions for all of them. I think the important point about the topical medications is as a patient's psoriasis gets more severe, the difficulty you face, a patient faces, day in and day out putting these medications on becomes a little bit overwhelming to many patients, and they're not able to use them consistently, and patients can't comply with the medications. So the use of topical therapy for psoriasis, though many of them can be effective, is limited a little bit in patients who have more severe disease.

MABEL JONG: What about phototherapy? That sounds like a more aggressive form of treatment there.

MARK LEBWOHL, MD: There are three forms of phototherapy, and actually, if you count lasers, now a fourth form. Old-fashioned ultraviolet B has been around for more than 80 years, and is quite effective in a proportion of patients. Usually patients who respond to sunlight will get better with old-fashioned UVB.

There is a newer form of UVB called narrow band UVB. It hasn't been around as long, so we don't quite know the safety profile, but hopefully it'll be just as safe as old-fashioned UVB, and it is substantially more effective.

There is a form of light treatment called PUVA, in which patients ingest a pill, which is called a psoralen, and are then exposed to UVA. That is a very effective form of treatment for psoriasis. Unfortunately, it's associated with the development of skin cancers in patients who get it.

And of course, recently we have lasers that are effective for the treatment of psoriasis.

MABEL JONG: Are all of these treatments only available in your physician's office?

KENNETH GORDON, MD: In general, yes. There are some places that are trying to set up small offices for phototherapy, but in general they're given by a dermatologist.

MABEL JONG: In your practices, is this something that you would go automatically to if the case is severe?

KENNETH GORDON, MD: I don't always use phototherapy in more severe patients. There are a lot of variables that go into phototherapy. Amongst them is the patient's ability to come in for the treatments. Usually these treatments are three days a week, four days a week, five days a week in some cases, and a lot of patients who have busy schedules can't do that day in and day out. So for those patients, we sometimes don't use phototherapy, though it is a very effective means of treating psoriasis patients.

MABEL JONG: One of the oral medications available is methotrexate. Tell me about that.

KENNETH GORDON, MD: Methotrexate is a medicine that was first used for chemotherapy, and it can be effective in psoriasis. It's given once a week in various doses, and patients tend to do pretty well with the medication. The difficulty with methotrexate is that it can cause toxicities. The foremost in most dermatologists' minds is hepatic toxicity, problems with the liver. That requires patients having a liver biopsy to make sure that you're not developing any form of cirrhosis or hepatic fibrosis. But it is an effective therapy. It just needs to be monitored very carefully.

MABEL JONG: Cyclosporin may also be used. Can you talk about that?

MARK LEBWOHL, MD: That's a dramatic treatment for psoriasis, and the circumstances under which we would use that are, first of all, the patients has to have severe psoriasis. We would never use it in mild psoriasis because it is a drug which has many side effects. Secondly, it would have to be a patient who failed safer treatments such as phototherapy, or perhaps even methotrexate. If a patient tells me that they won't give up their one beer a week or two beers a week, which is something we would not allow a methotrexate patients to have, I might consider them for cyclosporin.

A woman who is pregnant and has severe psoriasis would be an ideal candidate for cyclosporin, because it's one of the few treatments we have other than phototherapy, other than UVB phototherapy, which is not contraindicated during pregnancy, so that might be a patient I would consider for cyclosporin.

MABEL JONG: There is something called a vitamin A derivative that's available out there for treatment. How effective are they?

MARK LEBWOHL, MD: By themselves, as monotherapy, used only by themselves, they are not that effective for most forms of psoriasis. They are very effective if they're used in combination with ultraviolet light -- PUVA or UVB. But again, as monotherapy, they're not that effective by themselves. They also, when you use it by itself, the doses used have significant side effects, such as hair loss, thinning of the nails, a sticky feeling to the skin, chapped lips, dry skin. They raise levels of fats in the blood, and probably the most serious side effect is they cause severe birth defects in women who become pregnant while they take them or for a period of time after. So there are a lot of drawbacks to their use, but if they're used intelligently, and I believe very low doses used with phototherapy, they can be very effective.

MABEL JONG: Do you ever use these medications together?

KENNETH GORDON, MD: At times, we can use the medications together. There are certain treatments, like combining methotrexate and cyclosporin, where you can theoretically decrease the amount used of both drugs and therefore lessen the potential of side effects from either one. However, that's really only used in the patients who are unable to be controlled with other therapies. I think that has to be reserved for the more severe patients.

MABEL JONG: When is rotational therapy appropriate? Dr. Lebwohl?

MARK LEBWOHL, MD: The reason that we rotate therapies at all is because of the toxicities of each of the treatments. Methotrexate causes liver damage. Cyclosporin causes kidney damage, probably, in most patients who take it long enough. PUVA causes skin cancers. And all of those toxicities are related to the amount of treatment you got. So if you can get a little bit of methotrexate, and before you even need a liver biopsy, switch off and go to another treatment, such as cyclosporin,, and before you run that year where you're going to start to get in trouble with your kidneys, you then switch off and go to another treatment, you may be able to minimize the toxicity of each of the treatments. That, of course, presupposes that the patient is going to respond to each of the treatments.

MABEL JONG: Do you have any final comments on the treatments available out there?

KENNETH GORDON, MD: I think the treatments can be effective. The one problem that we see with some of these treatments is that in some cases, particularly in cyclosporin, the therapy is so effective that it's hard to impress upon patients the toxicities of the medication, because suddenly they don't have this disease that's been affecting their lives to a great extent over time, so what we need to find is some therapies that have a good safety profile, that patients are able to use over time without having to rotate, if it is effective.

MABEL JONG: Dr. Mark Lebwohl, Dr. Ken Gordon, thank you so much for joining us today.

KENNETH GORDON, MD: Thank you.

MARK LEBWOHL, MD: A pleasure.

MABEL JONG: Thank you for watching our webcast. I'm Mabel Jong.

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